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Structured Reference Form

For applications to Specialty Training Programmes and Academic Training Programmes.

The doctor to whom this reference refers has applied for a specialty training placement and has given your name as a referee and we would be grateful if you could provide us with information required below. Please note we can only accept references on this structured reference form. This professional reference should verify factual information only; we do not require you to provide a personal testimonial or an assessment of the candidate. Your responses may be discussed with the applicant named above and/or his/her trainer. Your reference may also be made available to other departments within the NHS.

This reference form has been developed with the General Medical Council publication “Good Medical Practice” in mind. Your attention is drawn to the following paragraph:

“When providing references for colleagues, your comments must be honest and justifiable; you must include all relevant information which has a bearing on the colleague’s competence, performance, reliability and conduct” (GMC Good Medical Practice, Second Edition, July 1998 – The duties of a doctor registered with the General Medical Council, Item 11 – References.)

Candidates applying for academic posts must have one academic referee. The academic referee must complete all the academic sections, and as many of the other sections as possible. The referee may be someone who has knowledge of the candidate’s skills and attributes from some time ago, e.g. supervisor of an intercalated degree or special study module. It is important however that the academic referee carefully considers the suitability of the candidate for a long term career in academic medicine. Applicants are expected to discuss their application with the academic referee and to have established that the referee is happy to submit a reference. Information supplied by the academic referee may be considered by the committee conducting the interview.

Applicant Name:

Applicant GMC/GDC No

/ Applicant Ref No

Post Applied For:

Please confirm the applicant’s employment details that are covered by this reference:

Date started:

/ Date finished:

Position held by applicant:

(level and specialty)

/ Level / grade:
Specialty:

Trust name /location:

Your relationship to applicant:

/ Clinical Supervisor
Educational Supervisor
Other (please specify)
Was their attendance /timekeeping satisfactory?
YES NO If No, please give details
Was the applicant subject to any disciplinary procedure, formal or otherwise, during their time with you?
YES NO If Yes, please give details:
The post applied for is exempt from the provision of section 4 (2) of the Rehabilitation of Offenders Act 1974 (exceptions order 1975). Under this order are you aware of any criminal convictions or cautions which may affect the applicant’s suitability for the post?*
YES NO If Yes, please give details:
*It is contrary to the Act for referees not to reveal any information they may have, concerning convictions which may otherwise be considered “spent” in relation to this application which you consider relevant to the applicant’s suitability for employment
Would you be happy to work with this doctor again? / YES NO
Are you able to recommend this applicant for the post they have applied for? / YES NO
If you have any other comments regarding this applicant and his/her application for this post, please give details here:
SIGNATURE / NAME (print in block capitals)
POSITION HELD / CONTACT TELEPHONE NO.
Name of hospital or training practice / E-MAIL ADDRESS
Your UK GMC Number / If NOT registered with the UK GMC: Give name of your registering body & Your Registration Number:
Full Postal Address / If not registered with the UK GMC please attach photocopy evidence of your professional status to this reference
DATE (dd/mm/yyyy)
It is essential that this form is stamped with an official hospital stamp. If no stamp is available, please attach a compliment slip signed by the consultant providing the reference. Forms received without a stamp or a signed compliment slip will be returned.
Official hospital stamp (or training practice stamp) / Thank you for completing this reference.
This form should be handed back to the applicant in a sealed envelope. If you have returned the completed form by e-mail, please ensure that a paper copy is returned by post.

Academic candidate section: (Academic referees must complete this section. Clinical referees may be in a position to complete this section if supplying a reference for a candidate applying for an academic post)

Knowledge and achievements - Demonstrates general knowledge / broad interest in science and academic medicine.

1 / 2 / 3 / 4
Below average knowledge in science and academic medicine / Average knowledge in science and academic medicine / Good knowledge in science and academic medicine / Excellent knowledge in science and academic medicine
Comments / evidence:

Commitment to an academic career - Demonstration of understanding and commitment to academic career

1 / 2 / 3 / 4
Has shown no interest in an academic career. / Limited interest in an academic career / Positive interest in an academic career / Actively seeking out academic opportunities for future career.
Comments / evidence:

Academic potential - Demonstrates potential for a career in education / research through scientific publications and presentations.

1 / 2 / 3 / 4
No evidence of participation in audit, teaching or research / Some evidence of participation in audit, teaching or research / Active participation in audit, teaching or research. / Leading role for audit, teaching or research.
Comments / evidence:

Academic Potential – Potential to innovate by creating new ideas and influencing others.

1 / 2 / 3 / 4
Fails to generate ideas or solutions that are accepted by others. / Generates new ideas and solutions with mixed results / Generates new ideas and solutions with mainly positive results on the team. / Generates new ideas and solutions that have a positive impact on the team
Comments / evidence: